THYROID-PARATHYROID medical surgical nursing

Med surg

1. THYROID AND PARATHYROID DISORDERS SHEEN MARK T. BILBAO, RN MAN LEVEL 4 FACULTY UNIVERSITY OF CEBU - BANILAD CAMPUS COLLEGE OF NURSING

2. GOITER

3. GOITER Enlargement of the thyroid gland Usually caused by an iodine-deficient diet

4. Usually caused by an iodine-deficient diet Foods rich in iodine: Seaweeds Most fresh fish Sea salt Iodized salt

5. TYPES OF GOITER Toxic goiter – accompanied by hyperthyroidism Non-toxic goiter – associated with a euthyroid state Simple/colloid goiter – caused by iron deficiency; usually asymptomatic Nodular goiter – may be due to hyperplasia; asymptomatic; some may become malignant & some associated with a hyperthyroid state

6. HYPOTHYROIDISM

7. HYPOTHYROIDISM Deficiency of the thyroid hormones O ccurs most frequently in older women

8. Causes: Autoimmune thyroiditis (Hashimoto’s disease) Radioiodine (I131) or antithyroid drug therapy Thyroidectomy Central hypothyroidism Thyroid deficiency present at birth: CRETINISM

9. ASSESSMENT Clinical manifestations (adults) are based on 3 concepts: 1. Decreased metabolic rate 2. Decreased body heat production 3. Hypercalcemia – leads to decreased neuromuscular irritability

10. SIGNS & SYMPTOMS - extreme fatigue - hair loss, brittle nails & dry skin - numbness & tingling of fingers - menstrual disturbances, loss of libido - Myxedema - weight gain, subnormal temperature, & HR, cold intolerance - thickened skin, hair thins &B falls out - dulled mental processes, apathy - slow speech, husky hoarse voice, enlarged tongue, hands & feet; deafness may occur - constipation - personality and cognitive changes

11. - Myxedema coma – rare, life-threatening - hypothermia - depressed respiratory drive - unconsciousness - precipitated by infection/systemic disease, use of sedatives/opioid analgesics, cold Complications : Pleural effusion, pericardial effusion, respiratory muscle weakness, increased serum cholesterol level, CAD, poor left ventricular function.

12. “Everything is low, slow and dry.” In myxedema coma, all vital signs are profoundly depressed. It is potentially fatal.

13. NURSING PROCESS

14. NURSING DIAGNOSES Activity intolerance r/t fatigue and depressed cognitive process Risk for imbalanced body temperature Constipation r/t depressed GI function Deficient knowledge about therapeutic regimen for lifelong thyroid replacement therapy Ineffective breathing pattern r/t depressed ventilation Disturbed thought processes r/t depressed metabolism and altered cardiovascular and respiratory status

15. PLANNING Medical Management Goal: To restore a normal metabolic state by replacing the missing hormone Increased participation in activities & increased dependence Maintenance of normal body temperature Return of normal bowel function Knowledge and acceptance of prescribed therapeutic regimen Improved respiratory status and maintenance of normal breathing pattern Improved thought processes Absence of complications

16. INTERVENTIONS Administer pharmacologic medication: Synthetic levothyroxine (Synthroid or Levothyroid ) monitor for s/s of angina, ⇧ BP & tachycardia Take in the morning without food May cause bone loss & osteoporosis IV administration (if myxedema coma) continued with oral therapy Drug interactions: increase: blood sugar levels, effects of digitalis glycosides, anticoagulants, indomethacin phenytoin (Dilantin) & TCA’s increase effects of thyroid hormone meds

17. INTERVENTIONS Corticosteroids Monitor vital functions ABG, pulse oximetry Administer fluids cautiously Deep breathing & coughing exercises, incentive spirometry Administer hypnotics and sedatives with caution Maintain patent airway through suction & ventilator support

18. INTERVENTIONS Corticosteroids con’t . Promote independence in self-care activities Provide extra layer of clothing or extra blanket Manage constipation Improve thought process orient to time, place, and person provide stimulation through conversation and nonthreatening activities monitor cognitive & mental processes

19. INTERVENTIONS Corticosteroids con’t . Promote independence in self-care activities Provide extra layer of clothing or extra blanket Manage constipation Improve thought process orient to time, place, and person provide stimulation through conversation and nonthreatening activities monitor cognitive & mental processes

20. INTERVENTIONS Corticosteroids con’t . Monitor & manage complications ⇩ LOC, dementia V/S Difficulty in awakening patient Turn & reposition at intervals to avoid risks associated with immobility  

21. INTERVENTIONS Corticosteroids con’t . Teach patients on self-care desired action & side effects of meds importance of continuing meds as prescribed even after s/s improve nutrition & diet ( high fiber, low calorie, adequate fluid intake) to promote weight loss & normal bowel patterns Foods that can inhibit thyrod secretion: strawberries, peaches, pears, cabbage, turnips, spinach, Brussel sprouts, cauliflower, radish, peas Avoid infections Prevention: screening of TSH levels recommended for women >50 y.o . with 1 or more symptoms

22. EVALUATION Reports decreased level of fatigue; no chest pain or breathlessness Maintains baseline body temperature Reports normal bowel function Describes therapeutic regimen correctly Shows improved respiratory status & maintenance of normal respiratory rate, depth, and pattern Shows improved cognitive functioning

23. HYPERTHYROIDISM

24. HYPERTHYROIDISM Hypersecretion of thyroid hormones Severe form: THYROID STORM/ THYROTOXIC CRISIS (THYROTOXICOSIS) Occurs most frequently in older women

25. CAUSES Graves’ Disease (Toxic diffuse goiter) Toxic nodular goiter Thyroiditis after irradiation of the thyroid Presence of tumor Excessive ingestion of thyroid hormone Associated with emotional shock, stress, or infection

26. ASSESSMENT Clinical manifestations are based on 3 concepts: Increased metabolic rate Increased body heat production Hyp0calcemia – leads to increased neuromuscular irritability

27. ASSESSMENT Thyroid hormones increase response to catecholamines Presenting symptom: nervousness Emotionally hyperexcitable, irritable, and apprehensive Tachycardia, palpitations Heat intolerance Salmon skin Exophthalmos

28. ASSESSMENT Others: ⇧ appetite, progressive weight loss, abnormal muscular fatigability & weakness, amenorrhea, changes in bowel function Enlarged thyroid gland Advanced cases: ⇩ serum TSH, increased free T4, increased radioactive iodine uptake

29. ASSESSMENT THYROID STORM/THYROTOXIC CRISIS: Hyperpyrexia (above 38.5°C) extreme tachycardia (>130 bpm) exaggerated s/s of hyperthyroidism with disturbances of a major system altered mental state Precipitated by stress – injury, infection, surgery, tooth extraction, DKA, pregnancy abrupt withdrawal of antithyroid meds Complications: dysrhythmias, heart failure, osteoporosis, and fractures

30. “Everything is high, fast and wet.” Eye manifestations ( exopththalmos , lid lag, bright-eyed stare

31. NURSING PROCESS

32. NURSING DIAGNOSES Imbalanced nutrition: less than body requirements r/t exaggerated metabolic rate, excessive appetite, and increased GI activity Ineffective coping r/t irritability, hyperexcitability, apprehension, and emotional instability Low self-esteem r/t changes in appearance, excessive appetite, and weight loss Altered body temperature

33. PLANNING Medical Management Goal: To reduce thyroid hyperactivity Improve nutritional status Improve coping ability Improve self-esteem Maintenance of normal body temperature Absence of complications

34. INTERVENTIONS Administer pharmacologic medications: Radioactive Iodine Therapy Use of irradiation with the radioisotope iodine 131 Monitor for hypothyroidism Contraindicated during pregnancy & BF Place pt on isolation for a few days – use gloves when handling body secretions

35. INTERVENTIONS Antithyroid medications Action: block the utilization of iodine by interfering with the iodination of tyrosine and coupling of iodotyrosines in the synthesis of thyroid hormones Agents: Propylthiouracil (PTU) Methimazole ( Tapazole ) Toxic complications: fever, rash, urticaria, agranulocytosis, thrombocytopenia, pharyngitis, mouth ulcers Instruct not to use decongestants for nasal stuffiness

36. INTERVENTIONS Iodine or Iodide compounds suppresses release of thyroid hormone/ reduce activity of thyroid hormone and the vascularity of the thyroid gland usually given with antithyroid meds to prepare the patient for surgery give with milk or fruit juice, using straw avoid cough medications, expectorants, bronchodilators, and salt substitutes monitor for iodine toxicity ( iodism ): swelling of the buccal mucosa, excessive salivation, coryza, skin eruptions

37. Potassium iodide (KI)

38. Lugol’s solution

39. Saturated solution of potassium iodide (SSKI)

40. INTERVENTIONS Other medications: Beta-adrenergic blocking agents - Reduces peripheral symptoms, myocardial oxygen consumption, heart rate and improve myocardial efficiency b. Glucocorticoids (dexamethasone)

41. SURGICAL MANAGEMENT Subtotal thyroidectomy Preop: Promote euthyroid state

42. SURGICAL MANAGEMENT Subtotal thyroidectomy Postop: Position: fowlers with head, neck, and shoulders erect Monitor for bleeding and edema Monitor for hypocalcemia Assess for recurrent laryngeal nerve damage Monitor for thyroid storm

43. Improve nutritional status Small frequent feedings Replace fluids lost through diarrhea and diaphoresis Avoid highly-seasoned foods and stimulants such as coffee, tea, cola, and alcohol High calorie, high protein foods Monitor weight and dietary intake

44. Provide a non-stimulating, quiet, and cool environment Change beddings & clothing as needed; give cool baths, cool or cold fluids Improve self-esteem Eye care and protection for ocular changes – instill artificial tears and wear dark sunglasses under the sun

45. Monitor s/s of thyroid storm, cardiac and respiratory function Monitor ECG, ABG, pulse oximetry Administer oxygen Teach patients on self-care desired action & side effects of meds importance of continuing meds indefinitely & consequences of failing to take meds avoid stressful situations that may precipitate thyroid storm s/s of hypothyroidism

46. EVALUATION Shows improved nutritional status Demonstrates effective coping methods Achieves increased self-esteem

47. hypoparathyroidism

48. Hypoparathyroidism Hyposecretion of parathormone Characterized by: decreased intestinal absorption of dietary calcium and decreased resorption of calcium from bone

49. Causes Interruption in blood supply or surgical removal of parathyroid gland after thyroidectomy, parathyroidectomy, or radical neck dissection Atrophy of the parathyroid glands

50. Assessment Clinical manifestations are based on: hyperphosphatemia Hypocalcemia: causes irritability of neuromuscular system

51. Manifestations Chief symptom: tetany Latent tetany: Numbness, tingling, and cramps in the extremities; Stiffness in hands and feet

52. Manifestations (+) Trousseau’s sign occluding blood flow to the arm for 3 mins with a BP cuff induces carpopedal spasm (+) Chvostek’s sign sharp tapping over the facial nerve just in front of the parotid gland and anterior to the ear causes spasm or twitching of the mouth, nose, and eye

53. Manifestations Overt tetany: Bronchospasm laryngeal spasm carpopedal spasm dyphagia , photophobia cardiac dysrhythmias seizures Anxiety, irritability, depression, delirium ECG changes and hypotension

54. Laboratory Findings Overt tetany: Bronchospasm laryngeal spasm carpopedal spasm dyphagia , photophobia cardiac dysrhythmias seizures Anxiety, irritability, depression, delirium ECG changes and hypotension

55. NURSING PROCESS

56. NURSING DIAGNOSES Ineffective airway clearance r/t spasm of airways Risk for injury and aspiration r/t seizure activity Ineffective cardiac tissue perfusion r/t altered rate and rhythm of contraction of the heart

57. PLANNING Promote and maintain airway clearance Promote safety and prevent injury Absence of complications

58. INTERVENTIONS Medical management goal: To increase serum Ca to 9 – 10 mg/dL and eliminate symptoms of hypoparathyroidism and hypocalcemia

59. INTERVENTIONS For hypocalcemia and tetany after thyroidectomy: administer IV calcium gluconate slowly and cautiously place pt. on continuous cardiac monitoring for cardiac dysrhythmias Parenteral parathormone

60. INTERVENTIONS Provide an environment free of noise, drafts, bright lights, or sudden movement Place on seizure precaution Prepare for tracheostomy or mechanical ventilation, plus bronchodilators

61. INTERVENTIONS Diet: high in calcium, low in phosphorus Avoid milk, milk products, and egg yolk Avoid spinach Oral calcium supplements Aluminum hydroxide ( Gelusil , Amphojel ) Vitamin D preparation ( eg , dihydrotachysterol , ergocalciferol, or cholecalciferol)

62. EVALUATION Absence of respiratory difficulties Free from injury and aspiration Absence of cardiac dysrhythmias

63. HYPERPARATHYROIDISM

64. Hyperparathyroidism Overproduction of parathormone Characterized by: bone decalcification high serum Ca levels ⇢ development of renal calculi

65. Causes Primary hyperparathyroidism (PHPT) Adenoma due to overgrowth of cells in one of the glands; 85% Hyperplasia in more than one gland; 15% Parathyroid cancer; <1% (rare) Secondary hyperparathyroidism (SHPT) Excessive secretion of parathyroid hormone (PTH) in response to hypocalcemia and associated hyperplasia Seen in patients with chronic renal failure (CRF)

66. Assessment Clinical manifestations are based on: Hypercalcemia: decreases excitation potential of nerve and muscle tissue Bone demineralization

67. Manifestations May have no symptoms ⇧ serum calcium level: Apathy Fatigue Muscle weakness Nausea, vomiting, constipation Hypertension, cardiac dysrhythmias

68. Manifestations Psychological effects: irritability and neurosis to psychoses Formation of renal stones, abdominal pain and hematuria Complication: renal damage – obstruction, pyelonephritis, and renal failure

69. Manifestations Musculoskeletal symptoms: Skeletal pain and tenderness Pain on weight-bearing Pathologic fractures Deformities Shortening of body stature

70. Complication HYPERCALCEMIC CRISIS Serum Ca >15 mg/dL Life-threatening neurologic, CV, and renal symptoms

71. NURSING PROCESS

72. Nursing Diagnoses Risk for injury r/t demineralization of bone Impaired mobility r/t skeletal pain and pain on weight-bearing Ineffective renal tissue perfusion r/t presence of renal stones

73. Planning Promote safety Improve mobility Absence of renal complications

74. Interventions Prepare patient for surgery Parathyroidectomy : recommended treatment for primary disease Postop: constipation is common early postop complication: hypocalcemia – monitor for s/s of tetany

75. Interventions Hydration therapy OFI of 2000 mL or more Cranberry juice or cranberry extract tablets Avoid dehydration Avoid thiazide diuretics Move patient slowly and carefully

76. Interventions Encourage mobilization Administer oral phosphates – long-term use not recommended due to risk of ectopic calcium phosphate deposition in soft tissues Avoid a diet with restricted or excess calcium

77. Intervention (Hypercalcemic Crisis) Rehydration with IV fluids Diuretics Phosphate therapy Biphosphonates ( eg , etidronate [ Didronel ]) – prevent loss of bone density Pamidronate [ Aredia ]) – to treat high blood calcium levels; diseases that causes abnormal & weak bones Cytotoxic agents ( Mithramycin), calcitonin (to decrease skeletal Ca release and increase renal clearance of Ca), and dialysis

78. Evaluation Free from injury and fractures, identifies safety hazards and methods of injury prevention Improved mobility Absence of renal complications

79. END